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Vision Option:

Humana

Per Pay Period—Weekly

Employee Only $ .75 Dependent Information
We offer our employees the opportunity to cover their
Employee + Spouse $2.24 spouses and dependent children. Children can join or

remain on a parent’s vision plan until age 26. When a
Employee + Child(ren) $2.09
child turns 26, they will lose vision coverage on the last
Employee + Family $3.71 day of their birth month.

Frequency limitations are based on date of last service and not on calendar year.

Benefits—Vision 130 Plan In-Network Coverage

Copays:
Exam $10 Copay
Materials $15 Copay
Standard Contact Fitting Up to $55

Frequency:
Exams Every 12 Months
Lens Every 12 Months

Frames Every 24 months
Standard Plastic Lens:
Single Vision Covered in Full after Copay
Lined Bifocal Covered in Full after Copay

Lined Trifocal Covered in Full after Copay
Lenticular Covered in Full after Copay

Standard Progressive Add on to Bifocal Copay + $15
Scratch Resistant, UV Coating and Tints Covered in Full after $15 Copay
Frames:
Frames Allowance $130 Retail allowance + 20% off overage
Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Lens Allowance $130 Retail allowance + 15% off overage

Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the Benefit Summary or contact the carrier for specific details.

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